HospitalInspections.org

Based on document review and interview, the facility failed to document 100 percent COVID-19 vaccination status compliance for 1 (Y) of 34 personnel health files reviewed (total 2,718 hospital staff, providers, volunteers); and the facility lacked policy/procedure for additional precautions for staff who were not vaccinated due medical or religious exemptions. Findings include:

On 2/9/22 at approximately 1330, review of electronic health files with Employee Health Supervisor X revealed that staff member Y had a "non-compliant" with COVID-19 vaccination status. It was determined that the employee was hired on 1/3/22 as a Patient Transportation Partner. The employee had worked since that time without a documented vaccination status. No explanation was provided as to why this employee was allowed to work without vaccination or exemption status by either Employee Health Supervisor X or Human Resources Manager V.

On 2/9/22 at approximately 1430, review of staff vaccination exemption lists revealed that the facility had over 100 hospital staff that worked at the facility with either medical or religious exemptions. Further interview with Human Resources Manager V and Employee Health Supervisor X , on 2/9/22 at 1445, revealed that they were unaware of any additional measures that unvaccinated staff observed. Also on 2/9/22 at 1445, interview with Quality Facilitator E revealed that the facility did not have written policies/procedures for additional precautions specified for unvaccinated staff working under exemptions or new hires. On 2/9/22 at approximately 1615, interview with Compliance Staff Z verified that the facility did not have policies/procedures that addressed additional precautions or measures for the unvaccinated.